Dangerous Liaisons: Rape and HIV
Pink flowers floating the pool, blossoms opening in love. In a ritual for women of the Yucatan Peninsula in Central America, a hollow is made in the earth and a woman bathes there naked in water up to her breasts. Other women cover the surface of the water with flowers and dance around her singing and praying in order to heal her and to demonstrate ... the "nurturing effect of tribal sisterhood." -- MOTHERPEACE, 1981
Though it's not quite the same, the "nurturing power of sisterhood" is alive in New York City in the form of rape crisis intervention services -- hotlines, individual counseling, and support groups for women rape survivors. Women are comforted and counseled, for the most part by other women. Men usually are part of the equation only when the police officers responding to or investigating a rape or the doctor who medically examines the survivor is male.
Someone, Help Me Through It
When a person's vagina, anus, or mouth is forcibly penetrated by a penis or an object, it is rape. A person who is raped may be exposed to HIV.
The basic services available to people (women and men; see I Am a Man. Yes I Am.) who have been raped are rape and sexual assault hotlines operated by hospitals, police departments, or private organizations; rape crisis advocacy support in hospital emergency rooms; short-term counseling following crisis intervention; and ongoing long-term counseling. Rape crisis intervention workers in emergency rooms have by far the most direct and intimate contact with survivors. It is here that HIV testing and post-rape HIV prophylaxis will most likely be introduced, although a rape survivor may certainly pose questions to a rape hotline worker or a short-term counselor.
What happens when a rape survivor enters an emergency room? When is information about HIV testing introduced into the conversation? What about post-exposure prophylaxis (PEP, an antiretroviral treatment used shortly after a person has been exposed to HIV in order to inhibit infection)?
Katherine Webber, clinical manager of the Mount Sinai Rape Crisis Intervention Program, describes how that program works:
"We have trained advocates who are on call 24 hours.... In the course of providing crisis intervention, supportive counseling, and emotional support while going through the medical exam, HIV will be discussed. Now, in the ideal situation, it's raised by the doctor, and we're there to provide some support around any feelings that arise about the possibility that they may have contracted HIV from the sexual assault. But if they do not bring it up, perhaps because they have not implemented the PEP protocol yet, or they just decide not to for whatever reason, we will discuss with the survivor that they might want to be tested and explain the testing procedures, or any other concerns they may be having.
"The second way that we treat survivors is through short-term counseling.... These people can come to us at any point after their sexual assault or rape. We have some clients who come in five years later, at which point it really is not introduced unless they say that they are HIV-positive or never felt concerned about it and never got tested. We would explore testing with them then. If they come in a month or a few months after the incident for counseling, and they feel it's something that they want to know about or we feel it something that needs to be introduced, we will bring it up. We won't apply any pressure though. Our philosophy is very client directed."
Louise Kindley, a social worker with the St. Luke's-Roosevelt Hospital Crime Victim Treatment Center, offers individual counseling and advocacy to survivors of sexual assault and domestic violence and facilitates groups for male and female survivors of childhood sexual abuse:
"The advocates are all volunteers from the community.... They are college students, housewives, businesspeople, men and women who have taken our training, who are on call for when a rape survivor is brought into the emergency department. Basically, their job is to be there as a support to the survivor, but also they're the ones who tend to orchestrate what happens. A doctor is not called to do the examination until the survivor has had a chance to talk with the advocate, who explains to the survivor what is going to be happening. Often, the police have already been called, and were the ones who brought the person into the hospital. However, if the police were not initially involved, they would not be contacted unless the survivor decides to take that action.
"The survivor has a choice as to whether or not to report the rape to the police, and whether or not to have a medical examination.... Now on top of this, we are going to have to have them talk about whether they want the PEP treatment. The doctor will be required to discuss this with the survivor.... The doctor is the one responsible for discussing STD treatment and pregnancy, so the HIV piece will obviously come in at this point. For some people, when they come into the hospital, HIV is paramount in their mind. It's their worst fear, that they are going to get HIV from the rape. It's never occurred to other people, so it's a new trauma to introduce.
"How difficult is it going to be for a survivor to make a decision about PEP treatment? We don't know because we've never had to do it before. In the past, we just told survivors that it was important to get medical follow-up and to come back to our counseling service for follow-up.... As a regular measure, professional counseling is recommended to every person who has been raped."
HIV Complicates an Already Complex Situation
HIV-related issues affect survivors, rape crisis workers, and medical staff, and are being intensely reviewed and discussed. For one thing, the recommended PEP protocol is not backed up by any substantial body of research specific to rape crisis intervention. It's just too new. The New York State Department of Health recommendations for rape crisis services are based on the CDC's guidelines for occupational exposures of health care workers to HIV.
Rick Sowadsky, the Nevada AIDS Hotline's Senior Communicable Disease Specialist, has developed a simple explanation of PEP and PEP guidelines for sexual exposures. It is based upon his own review of the CDC's recommendations and the most current preliminary research literature. His guidelines describe PEP as "a type of antiviral therapy for HIV that is designed to reduce (but not eliminate) the possibility of infection with the virus after a known exposure."
He then "generally" reviews the PEP recommendations based upon what is currently known (emphasis his):
"PEP after a sexual exposure MAY be considered if ALL of the following criteria are met: 1. A person has had a KNOWN HIGH RISK exposure to HIV, and 2. The person was exposed to another person who is KNOWN to have HIV (especially if they have a high viral load), or the other person is KNOWN to be at very high risk for HIV, AND 3. The exposure is an isolated incident, and future exposures are very unlikely, AND 4. The person is compliant with taking their medications, AND 5. Antiviral medications are not contraindicated in their case (not all people can take these medications), AND 6. Treatment begins preferably within several hours after the high risk exposure, or if necessary, up to 24-36 hours after the high-risk exposure. The benefits of beginning treatment beyond 36 hours are not known. PEP usually involves sustained treatment for approximately 4 weeks."
There is no consensus on these recommendations, and differences of opinion may certainly play a part in this unfolding PEP treatment situation. For instance, Sowadsky includes in his list of circumstances under which PEP is not recommended after a sexual exposure, "... treating people who have had exposures to a person whose HIV status is unknown, or whose risk factors are unknown." Yet, in "The Care of Persons with Recent Sexual Exposure to HIV," by Mitchell H. Katz, M.D., and Julie Louise Gerberding, M.D., M.P.H., in the February 15, 1998 Annals of Internal Medicine, "If the partner is unavailable or unwilling to be tested, treatment decisions should be based on the likelihood that the partner is HIV infected."
As director of the AIDS Project at the Lambda Legal Defense and Education Fund, Catherine Hanssens focuses on issues most likely to affect the lives of gay men and lesbians with HIV.
"Even if one were to do a viral load test and get as much information about the person accused of a rape as possible, and even if there were no question that this was the person who did it, people still have many questions about these guidelines for antivretroviral therapy. If we have the source person, the accused rapist, and we do a viral load test, these tests are only sensitive to a threshold of 200 to 500 copies per ml. In other words, even viral load tests don't pick up the amount, or won't confirm whether or not there is virus in this person's body, and yet we're asking a rape survivor to commit to about a four-week course of treatment prophylaxis. I've heard a doctor say that he wouldn't be comfortable going for prophylaxis based on that information.
"This is the kind of information on which any kind of recommendations regarding mandatory testing legislation should be based. Any PEP treatment recommendations or mandatory testing legislation should be useful to the person trying to make an informed decision -- in this case, the rape survivor."
Are rape crisis intervention staff comfortable with the PEP recommendations? How do they view the issues? A survivor often comes into an emergency room in a state of shock and is subject to the pressure of a medical examination and potential questioning by the police. Is it realistic to expect an informed decision about PEP treatment under such conditions?
St. Luke's/Roosevelt's Kindley doesn't think so:
"It seems like a terrible thing to say, but we're almost sorry that PEP treatment is now considered effective for survivors. We all want somebody to be protected as much as possible, and yet there is no way to make this kind of a decision in a completely clearheaded fashion. So, what that means is that the people who are helping the survivor have to be especially sensitive and clear about what all of this means. It will be challenging to train our advocates to try to help survivors to prioritize the decisions that have to be made."
Katherine Webber at Mount Sinai sees pros and cons to PEP treatment for rape survivors:
"Until we do have more information, I agree that it can be problematic for the survivor. I also think that it would be advantageous to have a mandated protocol for all the hospitals. It's complicated right now because what we've been finding is that it's very costly, and as a result, it's not clear if it's being introduced in a uniform way. Whether hospitals are going to use it is one question, and whether it's going to be used uniformly is a critical aspect to ensure that all survivors are made aware of it in some form.
"This issue is always complex around survivors and HIV, because it can scare them in a way that is not helpful at that time and may shift their anxiety to what may end up not actually being an issue for them. We see ourselves as doing client-oriented work, so we do need to make sure that they have this information.... What if they find out a month later that they could have had this but nobody told them, and the information could have kept them from becoming HIV-positive? On the other hand, I don't want the survivor to feel overwhelmed by that issue."
If that's not complicated enough, the resistance issue may come into play. What if the survivor is already HIV-positive but unaware of it and opts for PEP? Or a person may already be on a combination therapy but not provide that information. What if a person receives PEP but becomes positive later? And then there are confidentiality issues -- about both HIV status and being raped.
Potential complications pop up in many places, and in most cases rape survivors have had just one exposure contact. Just how much of a priority should recommending PEP treatment be under these conditions? Mount Sinai's Rape Crisis Intervention Program deals with many different emergency rooms. Will they have to train their advocates in different PEP protocols based upon what each hospital favors, or will recommendations for one standard for all hospitals become mandatory?
Other issues involve the monetary cost to the rape survivor, the insurance industry, or some other payer. According to San Francisco's PEP Project, the cost of PEP per patient for four weeks of drug therapy is from $500 to $1,000, a lot less than the cost of treating full-blown AIDS through the lifetime of the patient. Lawmakers have not put forth any comprehensive proposals for payment of HIV-related costs incurred by rape survivors.
According to Catherine Hanssens, "... advocates advised [the New Jersey legislature] that if it's medically appropriate based on counseling from the doctor, and the person chooses treatment, then treatment should be provided ... without any concern about that person's ability to pay. Unfortunately, HIV-related legislation is generally driven by ... political opportunity. The proposals that we deal with every year are rarely put forward by public health officials.... Instead, it is put through by politicians."
Another legal issue that gets entangled with the HIV health care concerns is the increasing number of survivors who report rapists complying when they were asked to wear condoms. According to Webber, "I think that this speaks to the perpetrator's fear of HIV. Certainly, there are some who don't care at all, who wouldn't even consider it, but more and more, I have heard stories like this. It's interesting that part of what's happened is that the request made by the survivor to the perpetrator is often used ... as evidence that she's complicit in the sexual act.... I think that this says that the perpetrators are aware that they can contract HIV. Certainly, they are not wearing a condom to protect the survivor."
These are only a few of the issues facing rape crisis workers, their clients, and the physicians who must attend to them. Is it any wonder that the simple ritual practices of the indigenous people of Central America sound so attractive? Our goals should be the same: for rape survivors to feel and know that they will be nurtured through the crisis, and that their health needs -- physical, mental, and emotional -- are a priority.
Photo by Fredda Tone
One rape crisis service interviewed for this article reported seeing only one male rape survivor per month. Another reported the case of a man who came into an emergency room because he was experiencing severe medical problems as the result of having been raped ten years earlier. Initially, he had not sought treatment.
Our society teaches men that somehow what makes a man a man instantly and mysteriously disappears when he is raped by another man. That is, of course, unless he's a gay man, or he's in prison.
If he's a gay man, the myth is that he enjoys sex with other men, and so what if it's violent -- gay men are into that sado-masochistic stuff anyway. If he's in prison, the myth is that he deserves what he gets as punishment and should have thought about life in prison before he did the crime.
What about men who are raped by women? Although we don't hear much about it, there have been a few men courageous enough to report having been raped by women. But for the most part we cling to our disbelief that men are raped by women -- unless the person who is raped is a boy, or a young man forced to have sex by an older woman.
There are many harmful myths about the substance of masculinity, homosexuality, and prisoner justice that keep us from offering men who are raped the support and healing they need. When men accept these myths as reality, they are inhibited from getting to base one, seeking treatment and support.